eMedicine Specialties > Gastroenterology > Intestine
Eosinophilic Gastroenteritis: Differential Diagnoses & Workup
Updated: Jun 15, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Drugs (acetylsalicylic acid [ASA], sulfonamides, penicillin, cephalosporin, carbamazepine, azathioprine, L-tryptophan, gold salts)
Parasites (Ancylostoma caninum, giardiasis, strongyloidosis, other zoonoses)
Cow milk enteropathy and related entities
Granulomatous gastritis
Hypereosinophilic syndrome
Gluten-sensitive enteropathy
Workup
Laboratory Studies
- The evaluation of eosinophilic gastroenteritis (EGE) starts with a comprehensive history and physical examination.
- General workup includes a CBC count and differential. Peripheral blood eosinophilia is found in 20-80% of cases.
- Average count is 2000 eosinophils (eos)/µL in patients with mucosal layer involvement, 1000 eos/µL in patients with muscular layer involvement, and 8000 eos/µL in patients with serosal involvement.
- Mean corpuscular volume
- Iron-deficiency anemia may be evident.
- Serum albumin may be low, especially in patients with mucosal layer involvement.
- Although usually unnecessary, fecal protein loss can be measured by measuring alpha1-antitrypsin in a 24-hour feces collection.
- This test is used to identify the inability to digest and absorb proteins in the GI tract.
- The normal value is 0-54 mg/dL. Patients with eosinophilic gastroenteritis have elevated alpha1-antitrypsin in their feces.
- Obtain a stool sample (minimum 2-g portion). Keep it refrigerated.
- Protein loss also can result in a low level of quantitative immunoglobulins.
- The erythrocyte sedimentation rate (ESR) and serum IgE level can be elevated.
- Obtain 3 separate stool specimens to rule out parasitic infection. Perform a wet mount or stain smear.
- Mild-to-moderate steatorrhea is present in approximately 30% of patients. This can be measured by qualitative and quantitative stool tests.
- Skin prick tests to inhalant allergens and food help identify sensitization to specific allergens.
- The diagnosis of eosinophilic gastroenteritis depends on microscopic evaluations of endoscopic biopsy specimens. Examine specimens from each intestinal segment with particular attention to the following: (1) eosinophil quantification; (2) the location of eosinophils especially if present in the intraepithelial, superficial mucosal, and intestinal crypts; (3) the presence of extracellular eosinophilic granules; (4) associated pathologic abnormalities; and (5) the absence of other primary disorders (ie, vasculitis).
Imaging Studies
- Radiographically, eosinophilic gastroenteritis does not have a pathognomic appearance. Radiographic changes are variable, nonspecific, and/or absent in at least 40% of patients.
- Gastric folds can be enlarged, with or without nodular filling defects.
- Valvular conniventes may be thickened and flattened. Strictures, ulceration, or polypoid lesions may occur.
- In eosinophilic gastroenteritis involving the muscle layer, localized involvement of the antrum and pylorus may occur, causing narrowing of the distal antrum and gastric retention. The small intestine also may be dilated, with an increase in the thickness of the folds. Prominent mucosal folds also may be observed in the colon.
- Rarely, diffuse esophageal narrowing or achalasialike motor abnormalities may occur.
- Further studies include ultrasound and CT scans.
- Ultrasound and CT scans may show thickened intestinal walls and, sometimes, localized lymphadenopathy.
- Ascitic fluid usually is detected in patients with serosal layer involvement.
Other Tests
- Exploratory laparotomy may be indicated, especially in patients with serosal eosinophilic gastroenteritis.
Procedures
- Endoscopy and biopsy
- Because of possible sampling error, when performing endoscopy, obtain at least 6 biopsy specimens from normal and abnormal areas of the bowel.
- Grossly prominent mucosal folds, hyperemia, ulceration, or nodularity may be apparent.
- In patients with esophageal or colonic symptoms, obtain additional biopsy specimens from the relevant sites to aid in the diagnosis. Gastroesophageal reflux can cause tissue eosinophilia in the distal esophagus.
- Patients with serosal disease present with ascites. Abdominal paracentesis demonstrates a sterile fluid with a high eosinophil count. Pleural effusion also may be present. Laparoscopy may show hyperemia and/or nodularity of the GI wall.
Histologic Findings
Histopathology usually demonstrates increased numbers of eosinophils (often >50 eos per high-power field) in the lamina propria. Large numbers of eosinophils often are present in the muscularis and serosal layers. The localized eosinophilic infiltrates may cause crypt hyperplasia, epithelial cell necrosis, and villous atrophy. The gross appearance of eosinophilic gastroenteritis upon endoscopy shows erythematous, friable, nodular, and, often, ulcerated mucosa. Diffuse enteritis with complete loss of villi, submucosal edema, infiltration of the GI wall, and fibrosis may be apparent. Mast cell infiltrates and hyperplastic mesenteric lymph nodes infiltrated with eosinophils may be present. Because of errors in sampling or to mucosal sparing, 10% of mucosal biopsies are not helpful to establish a diagnosis.
Histologic analysis of the small intestine reveals increased deposition of extracellular major basic proteins (MBPs) and eosinophilic cationic proteins (ECPs).
More on Eosinophilic Gastroenteritis |
| Overview: Eosinophilic Gastroenteritis |
 Differential Diagnoses & Workup: Eosinophilic Gastroenteritis |
| Treatment & Medication: Eosinophilic Gastroenteritis |
| Follow-up: Eosinophilic Gastroenteritis |
| Multimedia: Eosinophilic Gastroenteritis |
| References |
| « Previous Page | Next Page » |
References
Kim NI, Jo YJ, Song MH, et al. Clinical features of eosinophilic gastroenteritis [in Korean]. Korean J Gastroenterol. Oct 2004;44(4):217-23. [Medline].
Chen MJ, Chu CH, Lin SC, et al. Eosinophilic gastroenteritis: clinical experience with 15 patients. World J Gastroenterol. Dec 2003;9(12):2813-6. [Medline].
Venkataraman S, Ramakrishna BS, Mathan M, et al. Eosinophilic gastroenteritis--an Indian experience. Indian J Gastroenterol. Oct-Dec 1998;17(4):148-9. [Medline].
Aceves SS, Bastian JF, Newbury RO, et al. Oral viscous budesonide: a potential new therapy for eosinophilic esophagitis in children. Am J Gastroenterol. Oct 2007;102(10):2271-9; quiz 2280. [Medline].
Blanchard C, Wang N, Rothenberg ME. Eosinophilic esophagitis: pathogenesis, genetics, and therapy. J Allergy Clin Immunol. Nov 2006;118(5):1054-9. [Medline].
Buchman AL, Wolf D, Gramlich T. Eosinophilic gastrojejunitis associated with connective tissue disease. South Med J. Mar 1996;89(3):327-30. [Medline].
Chehade M, Magid MS, Mofidi S, et al. Allergic eosinophilic gastroenteritis with protein-losing enteropathy: intestinal pathology, clinical course, and long-term follow-up. J Pediatr Gastroenterol Nutr. May 2006;42(5):516-21. [Medline].
De Angelis P, Morino G, Pane A, et al. Eosinophilic esophagitis: management and pharmacotherapy. Expert Opin Pharmacother. Apr 2008;9(5):731-40. [Medline].
Desreumaux P, Bloget F, Seguy D, et al. Interleukin 3, granulocyte-macrophage colony-stimulating factor, and interleukin 5 in eosinophilic gastroenteritis. Gastroenterology. Mar 1996;110(3):768-74. [Medline].
Gay SP, Shaffer HA, Futterer SF, et al. Gastrointestinal case of the day. Eosinophilic gastroenteritis. AJR Am J Roentgenol. Jul 1996;167(1):241, 244. [Medline].
Jaffe JS, James SP, Mullins GE, et al. Evidence for an abnormal profile of interleukin-4 (IL-4), IL-5, and gamma-interferon (gamma-IFN) in peripheral blood T cells from patients with allergic eosinophilic gastroenteritis. J Clin Immunol. Sep 1994;14(5):299-309. [Medline].
Kelly KJ. Eosinophilic gastroenteritis. J Pediatr Gastroenterol Nutr. 2000;30 Suppl:S28-35. [Medline].
Khan S. Eosinophilic gastroenteritis. Best Pract Res Clin Gastroenterol. Apr 2005;19(2):177-98. [Medline].
Lee M, Hodges WG, Huggins TL, Lee EL. Eosinophilic gastroenteritis. South Med J. Feb 1996;89(2):189-94. [Medline].
Matsushita M, Hajiro K, Morita Y, et al. Eosinophilic gastroenteritis involving the entire digestive tract. Am J Gastroenterol. Oct 1995;90(10):1868-70. [Medline].
Moots RJ, Prouse P, Gumpel JM. Near fatal eosinophilic gastroenteritis responding to oral sodium chromoglycate. Gut. Sep 1988;29(9):1282-5. [Medline].
Neustrom MR, Friesen C. Treatment of eosinophilic gastroenteritis with montelukast. J Allergy Clin Immunol. Aug 1999;104(2 Pt 1):506. [Medline].
Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). J Allergy Clin Immunol. Jan 2004;113(1):11-28; quiz 29. [Medline].
Spergel JM, Beausoleil JL, Mascarenhas M, et al. The use of skin prick tests and patch tests to identify causative foods in eosinophilic esophagitis. J Allergy Clin Immunol. Feb 2002;109(2):363-8. [Medline].
Spergel JM, Shuker M. Nutritional management of eosinophilic esophagitis. Gastrointest Endosc Clin N Am. Jan 2008;18(1):179-94; xi. [Medline].
Talley N. Eosinophilic Gastroenteritis. In: Feldman M, Scharschmidt BF, Sleisenger M, Zorab R, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/ Management. 6th ed. Philadelphia, Pa: WB Saunders; 1998:1679-86.
Urek MC, Kujundzic M, Banic M, et al. Leukotriene receptor antagonists as potential steroid sparing agents in a patient with serosal eosinophilic gastroenteritis. Gut. Sep 2006;55(9):1363-4. [Medline].
Van Dellen RG, Lewis JC. Oral administration of cromolyn in a patient with protein-losing enteropathy, food allergy, and eosinophilic gastroenteritis. Mayo Clin Proc. May 1994;69(5):441-4. [Medline].
Zuo L, Rothenberg ME. Gastrointestinal eosinophilia. Immunol Allergy Clin North Am. Aug/2007;27(3):443-55. [Medline].
Further Reading
Keywords
eosinophilic gastroenteritis, EGE, eosinophilic gastroenteropathy, eosinophilic gastrointestinal disorders, EGID, eosinophilic gastritis
